Provider Demographics
NPI:1487913869
Name:MODERN DENTAL PROFESSIONALS UTAH, PC
Entity type:Organization
Organization Name:MODERN DENTAL PROFESSIONALS UTAH, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-955-1900
Mailing Address - Street 1:8415 DATAPOINT DR STE 1020
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3277
Mailing Address - Country:US
Mailing Address - Phone:210-929-2814
Mailing Address - Fax:210-615-3626
Practice Address - Street 1:10011 S CENTENNIAL PKWY STE 330
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-4178
Practice Address - Country:US
Practice Address - Phone:801-256-3700
Practice Address - Fax:801-576-1777
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MODERN DENTAL PROFESSIONALS UTAH, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-05-07
Last Update Date:2025-03-27
Deactivation Date:2024-04-08
Deactivation Code:
Reactivation Date:2025-01-06
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty